CT chest and upper abdomen

Loading Stack -

CT of the chest confirms the presence of innumerable small pulmonary nodules, which have a centrilobular predilection. Dependent changes are also present. The mediastinum is unremarkable.

CT of the upper abdomen demonstrates splenomegaly with multiple hypo-attenuating nodules, best seen on the portal venous phase.

1 study question available

Q: In a febrile patient what is the most likely cause of a miliary pattern? What is the differential?
show answer

A: Miliary tuberculosis is by far the most likely cause. Other causes include fungal, viral pneumonitis, nocardosis and
salmonella. Hypersensitivity pneumonitis can cause a miliary sort of pattern but if a fever is present it is usually mild.

This patient went on to have a bronchoscopy with bronchial washings obtained.

MICROSCOPY: Auramine-Rhodamine Stain: No Acid Fast Bacilli Detected. A negative acid-fast smear result does not exclude the presence of Mycobacterium species.

Case Discussion

Adalimumab (along with infliximab and etanercept) is a TNF inhibitor. As of 2008 adalimumab has been approved by the FDA for the treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease, moderate to severe chronic psoriasis and juvenile idiopathic arthritis.

Although most easily seen in the lungs, miliary TB is a systemic illness with solid organs also affected. In this case splenic and hepatic involvement is evident.